Judge Steven Leifman recently had a female defendant in his Miami courtroom who faced a minor criminal charge. He discovered she had experienced sexual trauma as a child and suffered from a schizoaffective mental disorder.

She initially was resistant to participating in the court's diversion program and getting mental healthcare. Leifman knew if he released her, she would be arrested and jailed again, leading to more trauma—and higher costs for taxpayers and the healthcare system. He talked her into participating in the court's residential treatment program followed by comprehensive outpatient recovery services.

"We need supportive housing and a case manager who can work with these individuals," said Leifman, who is nationally recognized for his work in improving Miami-Dade County's mental health system. "Most of the systematic change has to be done in each community, with the federal government providing the financing. There's not a silver bullet."

Policymakers and healthcare providers widely agree that the U.S. has lots of hard work ahead to improve its system for serving the millions of Americans suffering from serious mental illness and substance abuse. They currently are crowding the nation's streets, jails, prisons and hospital emergency departments, largely going without effective treatment and social services to enable them to live healthier, more productive lives. Research has shown that they die, on average, 25 years younger than other Americans due to untreated chronic medical conditions.

There's bipartisan support for stepped-up federal coordination and funding. The landmark 21st Century Cures Act, enacted last December, includes a package of reforms and grants. The law also created a first-ever HHS assistant secretary position to quarterback federal programs for mental health and substance abuse treatment. President Donald Trump has nominated Dr. Elinore McCance-Katz, an addiction psychiatrist and former medical director of the Substance Abuse and Mental Health Services Administration, for that position. At deadline, her nomination was awaiting action by the Senate Heath, Education, Labor and Pensions Committee.

In another sign of bipartisan support for expanded mental health programs, congressional leaders in May reached a compromise on a fiscal 2017 appropriations bill, rejecting a number of Trump's proposed cuts to health and social services programs. The bill, which will fund government operations through September, allocates nearly $800 million to fund a number of programs aimed at curbing the opioid epidemic. The deal also increases funding for mental health block grants by $30 million this year; the president had sought a 20% cut. Ten percent of that block grant is set aside for early intervention programs on serious mental illness. Research has shown that people with serious mental illness fare much better over their lifetime if their disease is detected and treated early.

'We have to treat it'

Despite the protection of funding for 2017, the outlook for fiscal 2018 is uncertain. There are worries about full funding of the numerous mental health and substance abuse initiatives for which the Cures Act authorized funding, including $500 million for opioid addiction treatment and $51.9 million to promote integration of primary and behavioral healthcare. Beyond that, the Republican drive to repeal and replace the Affordable Care Act could roll back the Medicaid expansion that has enabled millions of low-income people with mental illness and addiction problems to receive treatment.

"If the proposed cuts end up impacting the current funding for mental health, we could be in a situation where there is a sincere intention to give and an equally sincere effort to take away," said Paul Gionfriddo, CEO of Mental Health America, an advocacy group.

Rep. Tim Murphy (R-Pa.), chief sponsor of the Cures Act's mental health provisions, vowed to keep up the pressure for full funding. "Mental health and substance abuse are a massive problem and we have to treat it," he said in an interview. "It will be a challenge because of tight budgets, but we will continue to push hard."

Experts say even if the Cures Act reforms and grants are fully funded, the negative impact on the mental health system of repealing the ACA would swamp those advances. "It would be one step forward and 10 steps back," said Ron Honberg, a senior policy adviser at the National Alliance on Mental Illness.

The GOP replacement bill that narrowly passed the House in early May would effectively end the law's Medicaid expansion to low-income adults, and threaten its mandated benefits and pre-existing condition protections for privately insured people with mental health and substance abuse problems. In addition, state Medicaid managed-care programs would have the option to stop covering treatment for mental health and substance abuse. Those provisions could neuter a separate federal law requiring insurers to cover behavioral care on parity with physical care.

On top of that, the House GOP bill would cut overall Medicaid funding by $839 billion, or about 25%, over 10 years. Medicaid pays for about 25% of all mental healthcare in the U.S.

An estimated 30% of adults who have received coverage under the ACA's Medicaid expansion have a serious mental illness and/or substance abuse problems, and about 1.3 million people receive treatment for those disorders through that coverage.

Ohio Gov. John Kasich and other Republican governors have stressed that the Medicaid expansion has been key in enabling many people with opioid addiction to receive treatment. Medicaid pays for nearly half of all medication-assisted treatment for opioid addicts in Kentucky, Ohio and West Virginia, and 20% of addiction care nationally.

Murphy, who has faced criticism from mental health advocates for backing the ACA repeal-and-replace legislation, argues the House GOP bill would enhance behavioral care. The GOP bill, he noted, would offer states tens of billions of dollars through 2026 that could be used for mental health and substance abuse treatment.

That funding, he said, would do more than Medicaid expansion to encourage states to develop effective systems of care.

Rep. Joe Kennedy (D-Mass.), a strong proponent of improved coverage for mental healthcare, rejected that claim. "The additional funding doesn't come close to offsetting the damage of repealing the Affordable Care Act," he said in an interview. "Our (Republican) colleagues have gotten committed to repealing the law without acknowledging the millions of people suffering from mental illness who will be sacrificed."

Vacancies impeding progress

Besides the funding uncertainties, a major concern for mental health providers and advocates is SAMHSA's pace in implementing the ambitious mental health agenda laid out by the Cures Act. That implementation has been slowed by the Trump administration's delay in filling key posts at the agency.

Among other things, the legislation creates a federal inter-agency committee to make recommendations to Congress for better coordination of services for adults and children with a serious mental illness; establishes a National Mental Health and Substance Use Policy Laboratory to promote evidence-based service delivery models; and strengthens federal enforcement of insurers' compliance with mental health parity rules.

The law also calls for clarifying policy and offering training on when providers may disclose health information related to treatment of an adult with a mental health or substance abuse disorder, a pressing issue for providers. In addition, it establishes a pilot program to award grants for medical residents, fellows, nurse practitioners, psychologists and other professionals to provide mental health and substance abuse services in underserved communities. The shortage of mental health professionals is one of the biggest problems in the field.

Additionally, Trump didn't nominate McCance-Katz until late April. Her selection received harsh criticism from Murphy. He argued that she is too closely associated with the agency's previous problems—even though she publicly blasted the agency when she resigned in 2015 for not adequately addressing the treatment needs of people with serious mental illness.

"She was a little too silent when all those problems were occurring," Murphy said. "That concerns me."

Leifman, who reportedly was HHS Secretary Dr. Tom Price's top pick for the assistant secretary position, has a different view of McCance-Katz, who's currently chief medical officer in Rhode Island's office of behavioral healthcare. "I think it's a very good pick," he said. "She's very smart, she's very knowledgeable, and she has a really great background on addiction medicine."

Still, key Cures Act reforms likely will languish until McCance-Katz is confirmed by the Senate and other administrative posts at SAMHSA are filled.

"It's a little frustrating," Honberg said. "We have this new law and new opportunities. Some work is beginning on implementation, but creating the interdepartmental coordinating committee and establishing the substance abuse policy laboratory will require someone at the helm in the assistant secretary position."

SAMHSA says it's moving forward with the interdepartment coordinating committee. The agency currently is seeking representatives from various federal agencies and setting up a process for nominating public members, said Brian Altman, the acting director of legislation.

Therapy vs. punishment

Another major policy question is whether the Trump administration will focus on a therapeutic or punitive approach toward people with substance abuse problems. So far it's sent mixed signals.

To head a new President's Commission on Combating Drug Addiction and the Opioid Crisis, Trump appointed New Jersey Gov. Chris Christie, who has stressed rehabilitation during his governorship. Trump ordered the commission to produce final recommendations by October on improving the federal response to the drug addiction crisis.

Many wonder whether the commission is even necessary. "It seems to be revisiting a lot of territory that's already been covered by Congress and the previous administration," said Richard Frank, a professor of health economics at Harvard University who served in a top HHS post in the Obama administration. "The answer is to get money out the door and get programs up and running."

On the other hand, Attorney General Jeff Sessions has signaled a get-tough approach toward people who use or sell drugs. "We have too much of a tolerance for drug use," he said in a recent speech. "We need to say, as Nancy Reagan said, 'Just say no.' "

Experts are wary. "I'm hopeful they'll treat this primarily as a medical issue, which it is," Leifman said. "For some people, the criminal justice system does play a role to encourage them to get the services they need. However, if you set up systems appropriately, most individuals can and should be treated without ever coming into the criminal justice system."

Despite these concerns, providers and advocates fervently hope the Trump administration and the new assistant secretary succeed in beginning to transform the nation's broken system of mental health and addiction care. They hope the Cures Act provisions will be just the first of many reforms and new funding measures.

The end goal, many believe, is to streamline the labyrinth of programs at the federal, state and local levels to provide much easier access to comprehensive treatment and recovery services.

"One of the most important jobs for the new assistant secretary is that when people show up for services, they can get everything they need in one place," Leifman said. "Otherwise we're going to waste a lot of money, and people are going to continue to die."